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Registration Form admin 2018-12-19T09:46:03+00:00

OR

Complete below to be reviewed and approved

This is a medical consultation, and the doctors require the patient to be honest to ensure quality advice is provided.
Are you an athlete in a sport that subscribes to the WADA World Anti-Doping Code?*
- Yes
- No
What products are you interested in? (Tick all that apply)*
- Anti-ageing
- Muscle Building
- Fat loss/weight loss
- Safe Enhanced Tanning
- Injury Repair
- Increased Libido
- Hair Loss Solutions
- Energy increase
- Mood increase
- Better general health
What are some of you Goals?
What do you expect to achieve?
Do you have any blood tests done recently that will give us more information about you?
Name*
First Middle Last
Email address*
Enter Email Confirm Email
Address*
Street Address Suburb/City State / Province / Region ZIP / Postal Code Country
Phone Number*
Date of Birth*
Gender*
- Male
- Female
Sign up for our newsletter
Create Username*
Password*
Enter Password Confirm Password
Strength indicator
Weight (kg)*
Height (cm)*
Medical Background Incomplete
Do you experience any of the following?
Profuse sweating at night*
- Yes
- No
Please provide details
No interest in eating / Loss of appetite*
- Yes
- No
Please provide details
Unexplained weight loss or weight gain*
- Yes
- No
Please provide details
Any abnormal growth or lumps (including new beauty spots)*
- Yes
- No
Please provide details
Fevers / Flu like symptoms*
- Yes
- No
Please provide details
Exhaustion / fatigue*
- Yes
- No
If yes, do you know the reasons for these lumps or growths
Current Medical History
Untreated / Uncontrolled diabetes mellitus*
- Yes
- No
Uncontrolled thyroid disease*
- Yes
- No
Untreated / Uncontrolled heart disease*
- Yes
- No
hypertension*
- Yes
- No
Any form of cancer*
- Yes
- No
Do you have any current medical or surgical problems?*
- Yes
- No
Are you currently pregnant or breastfeeding?*
- Yes
- No
Past Medical History
Have you ever been admitted to hospital in your life past or recent?*
- Yes
- No
Details of Admission
Have you had any form of cancer in the past?*
- Yes
- No
Details of Cancer and remission
Thyroid disease*
- Yes
- No
Details of thyroid disease and treatment
heart disease*
- Yes
- No
Details of heart disease and treatment
Other
Medications
Do you smoke?*
- Yes
- No
Have you used peptides before?*
- Yes
- No
Did you have any side effects or problems?*
- Yes
- No
What were they?
Which peptides did you use, at what daily dose, for how long and when?
Current medications name
Daily dose / frequency
Add more
Allergies
Do you have any allergies to medications?*
- Yes
- No
Please detail
Medical Information
Agree*
- I certify that all the information provided on this application is accurate to my knowledge

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Our peptide supplements are prescribed by our anti-ageing professionals and compounded for your convenience in one of our Australian pharmacies.

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We have updated our website and processes to ensure that we are fully compliant with all relevant advertising laws concerning our products.

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